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234 Herbert, J. D., & Forman, E. M. (2010). Cross-cultural perspectives on posttraumatic stress. In G. M. Rosen & B. C. Frueh (Eds.), Clinician's Guide to Posttraumatic Stress Disorder (pp. 235-261). Hoboken, NJ: Wiley. TREATING THE FULL RANGE OF POSTTRAUMATIC REACTIONS Sbordone, R. J., & Liter, J, C. (1995), Mild traumatic brain injury does not proCHAPTER duce post-traumatic stress disorder. Brain Injury, 9( 4), 405-412. Schneiderman, A. 1., Braver, E. R., & Kang, H. K. (2008). Understanding sequelae the conof injury mechanisms and mild traumatic brain fliets in Iraq and Afghanistan: Persistent postconc traumatic stress disorder. American Joumal of Shalev, A. Y, & Freedman, S. (2005). PTSD 10 symptoms and post167(12),1446--1452. ~ terrorist attacks: A pro- Cross,Cultural Perspectives on Posttraumatic Stress 1188-1191 spective evaluation. American E, Ill. (2005). Treatment of K., Frank, E., Houck, P. R., & grief: A randomized controlled triaL Journal of the American Medical Association, 293(21), 2601-2608. van Griensven, E, Chakkraband, M, L. S., Thienkrua, W., Pengjunrr, W., Cardozo, B. L., Tantipiwatanaskul, P, et aL (2006). Mental health problems JAMES among adults in tsunami-affected areas in southern Thaibmd. Journal of the EVAN D. HERBERT M. FORMAN American Medical Association, 296(5),537-548. M ost cultures have historically framed reactions to tra:lma within the context of religion, with priests and shamans offering interof the causes or meanings of traumatic events, while also serv- ing in the role of healer. Within Western cultures, beginning in the mid-19th century, physicians gradually began to expand their to include psychological reactions to trauma. This process culminated in the creation of the medical diagnosis of posttraumatic stress disorder (PTSD) in 1980, which completed the transformation of reactions to trauma from the religious domain to a biomedical framework. This transled by American psychiatry, clinical nsycholo(!Y, and related fields, has exerted widespread influence. The adigm," in which human suffering and exist independent of local Hwnru'< to has resulted in a loss of that cultural factors an important role in the development and treatment of posttraumatic reactions. Despite such concerns, Western biomedical models of trauma and associated interventions are increasingly exported throughout the world. According to the United Nations, there are currently over 12.8 million displaced persons, 9.8 million refugees, and an additional 10J of concern" worldwide • ," 235 236 2006). traumatic increasingly events per modern diagnostic ~lallUctlU~ targeted Western interventions toward them. central thesis is twofold. cal 237 Posttraumatic Stress Disorder CROSS-CULTURAL PERSPECTIVES ON POSTTRAUMATIC STRESS a including factors typically shape reactions to traumatic events, be viewed as pathological. While such cultural effects impact many rnnnrtant in the case areas within a country (e.g., "Canadian maritime culture"), all the way down to local communities such as groups. When examining vocational, religious. or even to trauma, it is important to keep in the wide range reactions levels that make up such factors. Also, at level one examines, no culture is static. in addition to a cross-sectional comparison of at a given time point, one can compare the torical periods. an understanding of cultural factors is critical when and treating individuals posttrauma. We begin our discussion of these concerns by briefly considering what is meant by n We then review the predominant biomedical model of post- POSTTRAUMATIC STRESS DISORDER In terms of the classification, treatment American beliefs and practices have become traumatic reactions, focusing on the diagnostic construct of PTSD. We examine the many ways in which psychological, environmental, tural factors shape reactions to trauma, including the prevalence and nature of pathological reactions. We that cultural effects can be cross-sectionally (by comparing groups at a point in time), as well as historically across time (within a continuously evolving culture across time). We what of the third edition of the Jtagnost!c and Statistical Manual of Mental Disorders in 1980 (DSM; APA, 1980), and with respect to psychological reactions to trauma, prevailing has viewed posttraumatic reactions within a biomedical context-specifically as the medical condition of its introduction in the DSM-I11 (APA, 1980), interest in PTSD a historical perspec- tive yields on the question of cultural factors in posttraumatic reactions. stress, we consider the assessment and treatment of grown rapidly among scholars, and the public at large. the definition of what constitutes trauma, and therefore risk PTSD, has expanded in subsequent editiuns uf the DSM (e.g., DSM- PTSD, within a culture-sensitive framework. IV; APA, Qualifying traumatic events have been extended to learning about or witnessing another person's exposure to a life- WHAT IS CULTURE? Derivation of the word "culture" psy- the idea of fostering and nur- commonalities among individuals. While cultural anthropolohave not reached consensus on a definition term, the United Nations Educational, Scientific and Cultural Organization provides a useful description: "Culture should be regarded as the set of event. Traumatic events no longer need to be outside the range of normal experience, nor do they need to be standards external to the individual. Within ityof have experienced at least one event that traumatic stressor (Breslau & 2001). This gradual and of traum,l has led PTSD to become the tinctive spiritual, material, intellectual and emotional features of by which reactions to a wide range of adverse evet1($ are understood. or a social group ... in addition to art and literature, lifestyles, ways of Accompanying this development is the ever-increasing human (Summerfield, together, value systems, traditions and beliefs" (UNESCO, 2002). The term and can refer to broad groups that share certain beliefs extending across several nations by national boundaries "Western culture"), "French culture"), to of There are a variety of consequences model to understand as a "natural kind," As with 238 CROSS-CULTURAL PERSPECTIVES ON POSTTRAUMATIC conditions, PTSD is assumeJ other to STRESS Pnsnraumatic be 239 Across Culwres found. Terheggen, Stroebe, and Kleber ) documented that Tibetans itself consistently with a unique symptom ranked destruction of religious symbols as the most traumatic event tures, both at any given time point as well as possible, ahead of other events such as death of a friend or even way biomedical diseases work. However, unlike bone fractures or viral infections that may entail the same causal agents regardless of time or A biomedical perspective suggests that rates of PTSD conditions such as PTSD are presumably socially constructed and therefore culture-bound. consis- traumatic events. exposed to to this and between cultures. For example, studies of recent LDmugrants to industrialized countries as well as of Iutiona!s within developing coun- POSTTRAUMATIC RESPONSES ACROSS CULTURES tries reveal widely variable rares of PTSD (see Yeomans and 2009). estnnates of the of PTSD within a culture what consti- are highly variable depending on factors such as gender and ethnicity. of such events, varies The National ComorbiJity Survey fuund an overall rate of PTSD among An often overlooked aspect of PTSD is the fact that by culture. Summerfield American men of as compared to 20A°!..) among women (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Pule, Best, Ml.:'tzler, and There is nothing quintessential abullt a particular traumatic experience. The attitudes of wider society (which may over time) shape what individual victims feel has been done to them, and shape thc vocabulary they usc to describe whether or how they seck help, and thcir expectations of recovery. The more a society sees a traumatic cvent (rape, example) as a scriolls risk t,) the present or future hcalth and victim the nwre it may turn out to be. In other words, societally constructed ideas about outcomes, which carry a include the pronouncement:-. the mental health Mannar ( reviewed evidence that Latinos in the UniteJ States demonstrate higher rates of PTSD than white or black counterparts. The observatiun that posttraumatic reactions in other cultures du not necessarily conform to Western expectations is consistent with culturally sensitive research. Yeomans, Herbert and Forman (2008) used ,) of qualitative interviews by native speakers and swndardi:ed instruments to assess posttraumatic reactions among internally displaced in the central African nation of Burundi. In mJer to avoid respnns(:' ur contamination resulting from expectancies, measure of self-fulfilling prophecy (p. 232) trained native interviewers preceded the aSSessment c)f specific sympwms. All of the interviewees had experienced at least nne, and traumatic within one ceived by sexual are not ~o per- traumatic events. Content rather than intense foclls in Western socieries as a cnmll1un traumatic event to PTSD. An act of fellatil) between a pubt:'scent of the Interview data revealed that which ha,; received and an older man would be universally condemned as childhood sexual abuse Western However, such acts arc a COmml1I1 nte of passage among tracultures (Bo\-m, 1996). Even within American ture, the assumption of inevitable lasting traumatic effects of childhood abuse has been questioned (Rind, Tromovitch, and 1998). Outside the sexual realm, cultural dIfferences contmue to be symptoms. Assessment uf toms of somatization, anxiety, and depression, with relatively few symptoms of PTSD per se. Similarly, Baron (2002) found that the distress of Sudanese in Northern Uganda focused more lm material cun- cerns such as lack of food, poor health care, and the ongoing threat of violence rather than DsvcholOllical symptums. The majority did not distressing symptoms, and for thuse who of anxiety, somatic complaints, and these tended to take the fl)rl11 symptoms. 240 colleagues In their review of of those affected, of individuals who respond with persistent symptoms, posttraumatic reactions tend to differ across cultures. They noted that the intrusive symptoms of PTSD tended to occur across cultures, while symptoms were not consistently observed. Marsella suggested that PTSD symptoms Inay be hil2hest in cultures in which avoidance and in mainare more common, because these symptoms are 241 intervention" 853 ). among the minor- & ACfl),s Posttraumatic CROSS-CULTURAL PERSPECTIVES ON POSTTR.'\UMATIC' STRESS social support and other cultural factors can more than the actual traumatic event. Wang et al. (2000) compared the reactions of inhabitants in two villages, both hit by the mentioned severe earrhquake in northern China. Wang found that the village with the higher level of initial exposllre to the a higher level of post-earthquake support. Rather than rates of PTSD in accord with a dose-response model other aspects of the disorder. the town residents With greater exp(lsure actually had lower rares pf Culture and Resilience PTSD. Evidently, social sUl'purt f<lctors act as a strong buffer to promote and natured r",covery after trauma. who \'isit survivors of severe countries are often natural disasters in Times, by the resilience of the native David Brooks (2008) the As Sichuan Province in Western China quake that killed approximately POSTTRAUMATIC RESPONSES ACROSS HISTORY people on May 81>0V(:, displaying few signs of 2008. Despite of the literature the reactions of the survivors he perspecuve. That is, the nor- mative reactions to trauma vary interviews, and I don't in the minds of to which to 11IStorica I upbeat and by scenes of horrific devastation, the local These were another means nant cultural theories ahout the Consider t~)r over time, and retlect the domiof trauma (Herbert & \'arious trauma-related conditions that mid-19th century. on or go crazy. Work together. tn Similar observations to (Urrellt of the 2004 Asian tsunami for 280,000 deaths those from a mechanisms exist at individual and resilience in the face of adversity and enable normal helie\'ed that resultt·,1 in the symptoms of railway spine. demonstrated effects were due the culture and the in the Delboeuf, 1 to When care was taken to avoid expecrattons 242 CROSS-CULTURAL PERSPECTIVES ON POSTTRAUMATIC STRESS of any not be of symptoms, Charcot's hypnotic demonstrations could avoidof rest with an expectation of of pensions for two World Wars were century, railway spine was widely viewed as a posttraumatic psychological condition rather than a result of physical insult. Nevertheless, the specific symptoms of railway spine, particularly hysterical paralysis, stand 243 (1999) This led Hippolyte Bernheim and Joseph Delboeuf to emphasize the importance of fostering positive expectancies by means of an intervention they termed "psychotherapy." By the turn of the 20th Reactions flicts, with decreases in stark contrast to the symptom picture of modern PTSD. Similar lessons have been learned in military settings (Jones & 2005; Shephard, 2000). During the First World War, for exama large number of psychiatric causalities were evaluated as a consequence of the relentless trench warfare that took place. The most common symptom presentation among psychiatric casualties in that war included mutism, hysterical crying, and intractable trembling (termed Kriegszitterer or "war trembling" the Germans). Strong contrasts were noted between British soldiers' lack of improvement from "shell-shock" and French soldiers' swift recovery. This difference has been attributed to the fact that French soldiers were treated near the front without excessive messages of the seriousness of the condition, whereas British soldiers The popularity of currenr com- with a Western ethnocentric tive, hZls led to the Widespread is cultures. To the contrary, of po:ittraumatic symptoms time. The lessons of the past century, and in particular of the two Wars, highlight the critical importance of expectancies in the aftermath of trauma in shaping subsequent call into question the the nature of PTSD. were evacuated to hospitals in England. During the last two years of the war, the British also adopted a program of rapid psychotherapeutic intervention near the front lines, resulting in dramatic reductions in psychiatric casualties (Shephard, 2000). In anticipation of the entrance of the United States into the war, the American physician Thomas Salmon (1917) further developed the French and English program into a strategy that came to be known the acronym "PIE," for immediacy, and expectancy. Posttraumatic casualties were treated immediately and as close as possible to the front, \'iith clear expectancies for full improvement. After a brief rest period, soldiers were given meaningful work, and ASSESSMENT OF POSTTRAUMATIC REACTIONS With an appreciation for the variations that Occur in posttraumatic reacwe can now turn our attention to iSSlles of a:;sessment and treatment. A summary of key pOints for clinicians to conSider is Il1 Tahle 10.1 on the follOWing page. Assessment of posttraumatic reactions cussion of returned to their units as quickly as . the First World War, psychoanalysis became the dominant of psychopathology in both Europe and the United and the powerful role of suggestion in posttraumatic reactions was all but forgotten. The initial campaigns of the Second World War alarming psychiatric casualty rates, which at one point even exceeded the rate of troop mobilization (Glass, 1973). When Salmon's PIE was topics can he more Chinese and Latino men) than & Ibanez, 2001; Wang et with a dis- 244 Assessment of P,)sttraumatic Reactions CROSS-CULTURAL PERSPECTIVES ON POSTTRAUMATIC STRESS Table 1O.l Recommendations for a Culturally Informed Approach to Posttraumatic Stress Assessment • Assume neirher vulnerabiliry nor resilience. • AvoiJ framing questions in such a way as to lead [he ro conform ro Western expecrations of responses to trauma. Be aware rhat some mJidduals arc culturally normed • [0 minimize symptoms. • Cast a broad net !Ii rhe assessment of symptoms. • Beware of assessment tools thar are not carefully rranslated and validated into indigent languages. Formularion • Understand the impact of a traumatic ~\'ent within the context of the meaning ascflbed bv an individual's culture. Don't assume that events have the same impacr "etOSS individuals/cultures. • Acknowledge thar the way people cope with traumatic srress .-!,"N'n,~inv un a numj,cr of tactClfs, including cultural • Be aware of unconscious and conscious motivations to present with posttraumaric symprums, espeClally of PTSD. ro interH'ntion, wirh rreamlent Treatment • Do not suggest dlrecrly or mdirectly thar an indi\'lJual wit! exhibit chronic symptoms or wHI develop PTSD. Avoid or administer only With extreme caution. • Utilize culturally Cl)l1sistcnt sources of recovery (e.g., and ex tended social • Utilize CBT treatmenrs across cultures. with sensitivity to cultural differences and incorpl)raring relevant cultural practices. • Work [() reduce clinician-chent power imbalance that may be exacerbared by cultural differences. When conducting an assessment interview, clinicians must avoid suggestive questions that could shape an individual's memory of the traumatic event (Loftus, 1997) and/or establish morbid expectancies. This keen interviewing skills and sensitivity to the individual's current state of mind, In addition, the clinician must be mindful of relevant norms and mores. Resources such as the classic book Ethnicity and Family Therapy (McGoldrick, Giordano, & Garcia-Preto, 2005) are useful guides to typical cultural patterns associated with various ethnic groups. 245 A trusting therapeutic rapport is critical. and questions should be posed in an open-ended manner, especially initially. It is also critical for the clinician to suspend his or her own beliefs about how individuals "should" respond to traumatic events. In fact, it is helpful to go out of one's way to seek evidence that might contradict one's beliefs. Otherwise it is far too easy to succumb to what is known as "confirmation bias" (the highlighting and remembering of belief-congruent information over data that contradicts expectations). A variety of clinician-rated interviews and self-report questionnaires have been developed to assess posttraumatic symptums. such measures can provide useful quantitative symptom indices, they are not without limitations. All currently popular questionnaires and interview-hased measures were de\'eloped in English, and few have been translated and validated into other languages. Some attempts at translation have revealed linguistic difficulties, as some common English concepts do not exist in other cultures. For no word for "trauma" in Kurundi (the language of We are aware of one particular fmuma workshop in Burundi that spent hours attempting to translate the word, and finally chose a phrase that means "having one's heart turned upside down" (A. Niyongabo, personal communication, March 15, 2005). More fundamentally, there is the question of whether the concept of PTSD best reflects the experience of individuals in non-Western cultures, Consider that the most common approach to studying PTSD in non-Western countries typically involves these steps: translate PTSD symptoms into a native language checklist; approach an mdigent population; assess the listed symptoms; find the extent to which they are endorsed by traumatized groups; report PTSD rates; and conclude that PTSD exists in that culture. This exercise and the findings that result are then used to support PTSD's presumed universality. An example of such a study was conducted by McCall and Resick (Z003), They approached the Ju'hoansi tribe of Kalahari Bushmen, and with the help of village elders, identified individuals who had experienced domestic violence and who were symptomatic. They then presented these individuals wtth a translation of the DSM symptoms of PTSD. Not sumrisin"ly, 35°/il of the sample endorsed symptoms of PTSo. 246 CROSS-CULTURAL PERSPECTIVES UN PUSTTRAUMATIl STRESS of A critical problem with such an approach is that any to a certain will symptoms among distressed the endorsement of distress number of positive cases. of a prous little to symptoms suppose that we claim to have pused taxonomic entity. For we will call "post-ampua new dIagnostIc category, tee neurosis" (PAN). We claim that indi\'lduals who have lost a symptom pattern especially as result of trauma, will display a esteem, Assessment of Pllsttraumatlc Redctk,ns contexts, it is possible that IpYC'ln(if"r the could be retro- diagnosed with severe narcissistic disorder for want- ing to conquer the world, and a possible psychotic in multiple gods, including one who bolts to Earch and another who created love with issues may intll!ence the assessment of responses, especially in non-Western Individuals may be motivated to of hypersomnia, joint pain (outside uf the responses according to their rerceptions of what an dissociative episodes, and intennittenr periods of able response NOW, we translate a list of these symptoms into local approach victims of the civil \.\'ar in the Darfur region of Sudan, We seek out amputees in particular, read off (lur checklist, and ask if they these symptoms. We would not be surprised to find that number endorse some of the symptoms. Moreover, we a that ampltel'S endorse symptoms at a higher wte than non-amputees, and double-amputees endorse more symptoms than single amputees. these results validate the existence of PAN? Obviously nor. Note that the more distressed the group, the more likely will endorse symptoms of And of course, amputees are likely to he more disnon-amputees (and double arnrlltees more than amputees wtll endorse more symptoms of PAN, or of mOst anything else on a psychiatric checklist, for that matter, In order w assess how individual~ fwm elitlerem cultures to trauma, one must avoid elecontextualized checklists and 247 be. Such etlens are rarticularly problematic given the power imbalance that typically exists Western researchers and indigent porlilations. Western knowledge is often tacitly held tll to local context (Wessels, 1 This can result in individuals modifying their reports, and e\'en their actual experience, to match the percei\'ed researchers, One example of this effect was by Yeomans, and Forman (2008). In this study, indigent rural with greater exposure to Western PTSD psychoeducation reported more symptoms of to those with reports of traumatic reactions. Individuals in poverty-stricken societies may be motivated to report symptoms of psychulogical distress in hopes uf resources toward those determined to most needy (Kagel' & Naidoo, resources for individuab in soci- instead cast a broader net. As the example of PAN illustrates, the nature eties are sometimes contingent upon of j1usttrdllmatic responses assessed m For examole. current nolicy of the American Veterans Administration used, Mackowiak and Batren a function of the recently used the symp- tom checklist method in an (Alexander the Great, and Florence PTSD. Of course, an examination uf clers might very possibly have manifestatiun of symptoms. compensation for PTSD-related disability, but payment ceases if symptoms remit (Frueh, Smith, & Barker, 1 Such incentives to maintain, and report symptoms. This is not to suggest individuals are necessmily for many different elisorin the conclusion that these indi- viduals fulfilled criteria in each mstance, Thus, a depression checklist a Danic checklist to a could lead to a diagnosis of historical alld so on. of panic of symptoms undoubtedly sometimes occurs, Rather secondary gain may reinforce the actual experience of posttraumatic symptoms. A parallel example exists among for Dolitical asylum for whom ~uccess sometimes symptoms convince a of the on 243 Sensitive Treatment CROSS-C\:LTl1RAL PERSPECTIVES ON POSTTRAl't-IATIC STRESS that these incentives to I t is of their trauma exist for rhe clinician as well, if (or no other reason than wanting to their clients. These concerns have been discllssed Derek Suma British psychiatrist who views PTSD as a Western "invention" that has heen improperly imDosed on non-Western cultures (Summerfield, 2001; 2002; 2004; 2005). that rely on decontextualized checkissues related to perceived social desirabIltty, power and subject, and possible secondary gain, that strive to avoid these Tf"p'lrrh'>T factors in order to provide the most accurate picture of responses to trauma. Examples of good practices include so-called interviews by native interviewers that precede toms in order to avoid contamination. CULTURALLY SENSITIVE TREATMENT it is important to posttraumatic reactions. conventional wisdom among many mental of who experience traumatic events & Wilson, 2005). Most will be a variety of symptoms, but will recover within a matter of days to weeks. It is therefore important that interventions acknowledge and address the short-term distress that most people experience, while simultaneously supporting factors that encourage resilience. Second, it is becoming increasinglv clear in the immediate aftermath of traurna, people are to suggestions expectations of how one such messages may corne from the cultnre at large, they are especially powerful when delivered by health care professionals. If one Cl)!1\,eys expectations that the tr::luma is likely to result in persistent symptoms, the likelihood of such symptoms increases. If, on the other bnd. a experience as temporary, clinician expectatransient reactions to extraordinary circumstances, with the tion of full recovery, then the likelihood of recovery increases. 249 this overall pattern of resilience, a minority of continue to experience persistent and clinically significant symptoms. These individuals can benefit from SCientifically supported treatments. Yet, even this group should not be subjected to interventions that convey that drawn-out posttraumatic symptoms are the normative reaction to trauma. Clinicians should avoid over-natholo"izin(! an individual's reactions to adversity. tal disorder can lead to of Burundian war trauma survivors, those to attend an intervention workshop that educational component about PTSD had worse outcomes than those assigned to an eqUivalent inter\'ention without the component (Yeomans, Forman, & Herbert, in press). Taken together, these facts suggest that a phased approach to intervention is most appropriate, with interventions linked to the stage an individual finds him- or herself in relation to the traumatic event. Therefore, we discuss intervention efforts in three stages: the acute posttraumatic phase, the subacute phase, and the chronic phase (Herbert & Forman, 2006; Herbert & 2002). Acute Phase The most important priority immediately following a traumatic event is attending to the material needs the traumatized individual, including safety, food, and medical intervention, as needed. Psvcholo£!ical interventions should focus on restorative and measures, in the context of supportive, encouraging, and regarding full recovery. The individual's reactions should be without undue attention. This is nut the time for introspective analysis of the behind one's symptoms. Adequate rest is essential and medication can be prescribed as a sleep aid if neccssary. It is to cllcourage meantngtul activities to minimi:e murpreoccupation with the trauma and one's symptoms. This is not t\1 suggest that individuals sh,luld be encouraged w avoid thoughts of the trauma or distressing feelings associated with it, or from speakinl! about it if they wish. Indeed, a body of evidence suggests that cal avoidance can be quite prohlematic (e.g., Haves et a!., 2004). 250 CROSS-CULTURAL PERSPECTIVES ON POSTTRAl.IMATIC STRESS SClblfln? the idea is to encourage an individual to engage in meaningful actin- Trc,nment This type of inten'entitll1 can l<c 251 a ties to avoid morbid preoccupation with the traumatic event, to encour- a traumatic event to thuse whose symptl)mS 11<1\'e nnt age a sense of self-efficacy, and, as much as possible, to restore a sense resolved on their own. Research has shown that short-term CBT in the of normalcy. In this regard, indigenous cultural practices and rituals can aftermath of trauma can he effective in preventing the development l)f be especially helpful. Thus, in certain Native American and Southeast chronic problems (Bryant et aI., Asian cultures, a specific set of post-trauma rituals has developed cleanse the spirit and restore the soul (Wilson, 2006). In more collec- as d result of their symptoms. relevant. For example, after the 2008 Chinese earthquake, survivors Hearst-Ikeda, & should tivist cultures in particular, community-building efforts can be set about burying the dead, 1999, 2003; 1995). It is important to emphasize that this type of intervention to I nus, unlike aebnetmg programs that are improperly recommended for all sut\"ivnrs, short-term CBT pro- rubble, and reconstructing grams are rargeted only for individuals with clinically significant symptOIl1S schools and other communal buildings. Such community-building efforts that have liersisted weeks follmvine the event. As in the acute posttrau- have been empirically demonstrated to powerfully mitieate the effects be ;)voi(bl and th;lt of trauma in collectivist societies (Wang et al., clinicians shuuld promote forces ,)f emotional and and social support I and remain responses that follow take place within a cultural context. As important as what to do in the immediate aftermath of a trauma is what not to do. There is growing evidence that cenam common posttrau- Chronic Phase In the aftermath ot" trduma, SGme 10 experience a chronic symptom picture, with research literature supports the effectiveness of matic intervention programs (e.g., Critlcal Incident Stress Debriefing) interventions are at best ineffective, and at worse can be harmfuL such as the United continue been conducted with Western across for Clinical Excellence guidelines, explicitly caution against the use indi- posmaumatic psychological debriefing (Mayor, 2005). Certainly, clini- cators cians do not want to export to non-Western cultures a treatment model samples of trauma victims in a number has failed in its own the were diverse ies have Subacute Phase apy PTSD with racial minority populations. For instance, Even if morbid suggestions and expectations are caretully aVOIded, some individuals develop persistent symptoms and require tre;1tmenr. There is and Foa (1999) compared the responses of African Americans and Caucasians no clear consenslIs on exactly when normal, transient reactions cross the line to become "symptoms" of a disorder. As a general rule, we suggest that clinicians consider treatment within weeks Western effl'ctiveness studies of a traumatic event if (0 exposure trt'atmt'nt and found and improvement rates. Similarly, published series of uncon- trolled case studies concluded that exposure treatmen t reduced PTSD symptoms among low-income African American women reactions remain highly distressing and cause impairment in functioning, (Feske, 2001). Third, the specific techniques of CBT appear as iud£ed within the context of the individual's social group and culture. on sound, universal to what treatment is advised during the subacute phase, With several studies in Western countries have supported the use of short-term be to be based to cur across cultural lines (Rllsen & Davison, 2003). Fourth, there are a limited, but growing, set of studies of CBT-based interventions 252 for non-Western trauma victims that echo findings with Western 2001). In one study. 43 Sudanese tions (e.('., Paunovic & Uganda were randomly to receive either counseling, or psychoeducation cation, rsychoeducation plus narrative exposure therapy. Only those receiving exposure therapy experienced decreases in PTSD symptoms (Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004). On the basis of the above, we suggest th"lt clinicians operate on the that standard CBT interventions, especially interventions, should be the treatment of symptoms in persons of varying cultural backgrounds. One important caveat is the intervention program, while its core components, must to be culturallv sensitive, and appropri be ADDITIONAL STRATEGIES AND CONCERNS Stress inoculation training: Closely related to cognitive restructuring is Stress Inoculation Training (SIT; Meichenbaum, 1993), a multicomponent intervention comprised of guided self-dialogue, covert (visualizing the successful confrontation of an anxiety-provoking subvocally saying the situation), role-playing, and thought ,. to interrupt distressing ruminative thou"hts)' Althou£1h SIT appears to be exposure and 1991; Foa et suggests that such as thought may, in (Harvey & Bryant, 1998). the frequency and intensity of the Acceptance-based therapies: The paradoxical effects of thought stopping point to the more general role of psychological avoidance (i.e. the avoidance of aversive thoughts, memories, images, emotions, etc.; Herbert, & England, 2009) in the development and maintenance of PTSD. Several and Concerns Additional CIWSS-CULTURAL PERSPECTIVES ON POSTTRAUMATiC STRESS little has yet invesri- 2009; cognitive behavioral intervention Krakow et al., 2001) is a can target nightmares sleep disturbances associated with PTSD. In addition to standard sleep hygiene interventions, IRT involves having the patient write down a disturbing dream. The patient then modifies the dream however he or she desires, and the version is Initial At the same time, clinicians should he sensitive to when dreams are thoullllt to content Treatments to Avoid clinicians work with it is as impurtant to know treatments to avoid as what treatments to offer. For example, there is little evidence to suggest that traditional psychoanalytic or supportive psychotherapy are effective treatments for chronic posttraumatic symptoms. Another approach lacking support is that of "psychoeducation," at as it has been applied during in Western settings. As noted. there is, in some that Western concerns with culture. In this or a waithst control. The two workin that one intervention included a psychoeducational component. Results indicated that rhe psychoeducational component reduced the beneficial aspects of the interventiun program, presumably bv creating a morbid expectation on the part of the participants. or "energy" therapies have been A number of so-called aggressively promoted over the past for PTSD and rehlted Cllnthe in the treat- 253 254 References CROSS-CULTURAL PERSPECTiVES ON f\)STTRAU,lATlC STRESS 255 claim to operate via unusual mechanisms. and promise much more rapid clinical innovations into posttraumatic reactions. Such work has and effective treatment than standard d1erapies. includim, state-of-the- important fruit. \Ve have gained a clearer picture of normative reactions art exposure-based treatments. The evidence, EMDR has been shown to be to aversive events and factors that impede or promote recovery. treatments have been developed for those with persistent symptoms. And but no more so we have an increasingly clear sense of what not to do. existing treatments, and in some cases somewhat less so (Davidson & Parker, 2001; Devilly, 2002; Devilly & Spence, 1999) Importantly, the The picture is not entirely positive, however. Despite these achievements, the construct of PTSD has become reified, coinmonly viewed as a therapist-induced stimulation-does not contribute to its effects, sug- "natural kind" that exists relatively independent of its sociocultural con- cognitive-behavior and exposure- text. The results of cross-culwral and historical studies argue against thiS based techniques (Herbert ct aI., 2000). Similarly, there is no scientific perspective. There is mounting evidence that posttraumatic reactions are support for the miraculous claims made regarding TFT and its variants. by a variety of factors. Among the most critical of these factors that EMDR is but a variant Despite these negative findings, power therapies have been exported is the cultural context, which largely determines not only which events to Third World countries in curious forms are experienced as traumatic, but the nature and degree of for all manner aft1ic- tions. The interested clinician can do an Internet search for these meth- of subsequent reactions. History demonstrates that normative postrrau- ods to find various examples (e.g., work in Africa by the Association for matie symptoms have changed over time, while cross cultural research Fidd Therapy). We strongly rewmmend that therapists avoid shows that despite some commonalities, symptoms appear to differ across the power therapies, in favor of more scientifically supported treatments cultures even today. In addition, the popularity of PTSD tends to draw whose claims are consistent with the availahle evidence. attention away from one of the most striking facts about posttraumatic By hlf the most potentially damaging treatment approaches for posttraumatic reactions are programs aimed at "recovering" repressed mem- reactions: Most individuals show remarkable resilience even severe traumatic events. It is critical that mental health rather than inadvertently ories of traumatic events. Such therapies may involve any number of techniques, including hypnosis, age regression, and guided imagery, that ting it are Rather than subsuming all posttraumatic reactions under the rubric of a sin!ode biomedical hood sexual traumatic Research has now is inconsistent with the way memory works can actuthat these (Schacrer, create memories ot ahWie that never actually occurred, which are but miseuideJ efforts. del1Ce that such reactions are best understooJ in their context. Clinicians will find that their assessment and intervention efforts arc most when infused with culturally sensitive then experienced as veridical (Loftus, 2003). Therapists should such approaches, and should be eSDeciallv mindful of the risk of inadvermemories t:hrough CONCLUDING POINTS In the past three decades, a tremendous imerest in the effects of traumatic experiences has develnp<.'"d. Creation of the diagnostic construct of PTSD in 1980 served as a t:o jump-start research REFERENCES C. E., & Wilson, ]. P. PTSD, and resilience: A review ofthe literature. Trauma, Violence E.if Abuse, 6,195-216. Association (1980). Diagnosoc and statistical Hlmlu,!l disoTders (3rd ed.). Washington, DC: Author. American Psychiatric Association (1994). Diagnostic and statistic,!/ 1nal1lwl oj DC: Author. 256 and mental health services In ]. de Jong Baron, N. 157-203). Trauma in war and peace: New York: Kluwer A treatise on the nature and uses of New York: G. P. Putnam's Sons. 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